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Habit Reversal Training As a Treatment for Refractory OCD - a Case Study Habit reversal training as a treatment for refractory OCD - A case study Dillenburger, K. (2006). Habit reversal training as a treatment for refractory OCD - A case study. European Journal of Behavior Analysis, NA, 1-27. Published in: European Journal of Behavior Analysis Queen's University Belfast - Research Portal: Link to publication record in Queen's University Belfast Research Portal General rights Copyright for the publications made accessible via the Queen's University Belfast Research Portal is retained by the author(s) and / or other copyright owners and it is a condition of accessing these publications that users recognise and abide by the legal requirements associated with these rights. Take down policy The Research Portal is Queen's institutional repository that provides access to Queen's research output. Every effort has been made to ensure that content in the Research Portal does not infringe any person's rights, or applicable UK laws. If you discover content in the Research Portal that you believe breaches copyright or violates any law, please contact [email protected]. Download date:01. Oct. 2021 EUROPEAN JOURNAL OF BEHAVIOR ANALYSIS 2006, 7, xx - xx NUMBER 1 (SUMMER 2006) 1 Habit reversal training as a treatment for refractory OCD – A case study Karola Dillenburger1 Queen’s University of Belfast Nearly 4 million American men and women from all geographic, ethnic, or economic backgrounds are diagnosed with obsessive-compulsive disorder (OCD). While a combination of cognitive behaviour therapy (CBT) and psycho-pharmaca seems successful for 50% to 60% of patients, for intractable cases the typical recommendation is more medication or more CBT, however there is little evidence that the intensi- fied treatment regimen is successful. In this paper, habit reversal training, including awareness training, competing/other response training, self-monitoring, social support, and generalisation, was implemented with a long-term treatment-refractory OCD patient. Treatment gains and long-term maintenance indicate the potential of habit reversal procedures with these patients. Key words: Obsessional-compulsive disorder, habit reversal, relaxation, evidence-based practice, men- talism, CBT. According to the DSM-IV the diagnosis of person is aware that their behaviour is unusual Obsessive-Compulsive Disorder (OCD) is based (BABCP, 2004). Consequently, OCD can become on two components. “Obsessions are constant, in- a source of significant embarrassment and humili- trusive, unwanted thoughts that cause distressing ation and potentially interferes with general daily emotions. Compulsions are urges to do something living tasks, academic achievement, and profes- to lessen discomfort, usually discomfort that is sional conduct. Despite the fact that individuals caused by an obsession” (American Psychiatric often spend hours engaging in OCD behaviours, Association, 2000, p.1; see Kutchins, & Kirk, most people try to conceal their symptoms and 1999 for a critique of DSM). Four to six million experience high levels of emotional distress and adults and almost one million children suffer problems in interpersonal relationships. from OCD in the US alone (The OCD Resource Obsessions are persistent thoughts, impulses, Centre of South Florida, 2004) and it is thought ideas, or images that are experienced as inappro- that at some time of their lives about 2% of priate or intrusive, and cause distress or anxiety. the population suffer from some form of OCD Typically, obsessive thoughts include fear of (British Association for Behaviour and Cognitive contamination, unwarranted concerns about Psychotherapy, BABCP, 2004). personal safety and the safety of others, inflated sense of responsibility, or trepidations of com- Symptomatology mitting violent or sexually inappropriate acts. Compulsions are repetitive behaviours, such as Obsessions and compulsions can occur as repeated unnecessary hygiene routines, avoidance often as 100 times per day and in most cases the of contact with certain household items, switching off or on of electrical appliances, locking of doors This paper has been supported by The British Academy grant or windows, re-arranging household items, or No OCG-38918 and is based on a presentation at 2nd International Convention of Association for Behavior Analysis, Brazil (2003). hoarding of certain items. Compulsions can also Reprints can be obtained from Dr Karola Dillenburger, Queen’s include mental acts, such as praying, counting, University of Belfast, 6 College Park, Belfast BT7 1LP, Northern Ireland. E-mail: [email protected] or repeated silent self-talk. 1 2 Karola Dillenburger Epidemiology ment trap is considered typical for the commonly observed escalation of private as well as public By-and-large, it is thought that a complex OCD behaviours over time. Thus, OCD could combination of inherited biological and psycho- be considered as a habit disorder. Bienvenu et al. logical factors causes OCD, however the detail (2000) for example, suggests that OCD should of this remains participant to debate (Rachman, be considered a spectrum disorder that includes 1997; Salkovskis, 1985). For example, positron other habit disorders, such as somatoform (e.g., emission tomography (PET) scanning suggests body dysmorphic disorder and hypochondriasis) that areas in the brain that play a part in other and pathologic grooming conditions (e.g., nail neurological disorders show neurochemical ac- biting, skin picking, and trichotillomania). tivity in OCD patients that differs from that of people with no mental illness or those diagnosed Treatment with other mental illness (National Institute of Health, NIH, 2001). Changes in brain activ- In the past, OCD appeared difficult or near ity have been found to coincide with treatment impossible to treat (Ferguson & Taylor, 1980; (medication and behaviour therapy) as well as Pinkerton, Hughes, & Wenrich, 1984). Tradi- clinical improvement (NIH, 2001). Further tional approaches based on psychoanalysis were evidence of brain malfunction using magnetic largely unsuccessful. However, over recent years, a resonance imaging (MRI) showed that patients combination of psycho-pharmaca and Cognitive with OCD had significantly less white matter than Behaviour Therapy (CBT) resulted in treatment controls (Jenike, Rauch, Cummings, Savage, & becoming much more effective (OCD Centre Goodman, 1996), but it remains unclear whether Los Angeles, 2004). The most commonly used brain abnormalities are cause or effect of atypical psycho-pharmaca are the kind of Selective Sero- behaviours (Goddard, 2005). tonin Re-uptake Inhibitors (SSRIs) that are used While officially OCD is classified under for patients diagnosed with depression and related anxiety disorders (American Psychiatric Associa- disorders (Vallone, 1997). While SSRIs seem to tion, 2000), cognitive theorists view OCD as a be effective for 60-70% of people diagnosed with belief disorder (O’Connor, Aardena, & Pelissier, OCD, they are usually not effective if used in 2004), in which cognitive distortions are based isolation and patients can suffer severe withdrawal on irrational and specific dysfunctional beliefs symptoms when treatment is discontinued (Za- rather than on exaggeration of normal passing jecka, Tracy, & Mitchell, 1997). thoughts. Alternatively, behaviour analysts argue CBT is widely viewed as the primary psy- from a systemic and functional analytic point chological treatment of choice for individuals of view (Keenan & Dillenburger, 2004; McNa- diagnosed with OCD (Expert Consensus Panel, mara, 1979; Novak, 1996; Sturmey, 1996) that, 1997; Ladouceur, Freeston, Gagnon, Thibodeau, similar to other habit disorders, OCD has “sig- & Dumont, 1995). The main aim of cognitive nificant operant elements maintaining it” (Thyer, aspects of CBT is to alter the client’s irrational 1997, p.732). This view is supported by clinical obsessive thoughts and beliefs so that compulsive observations that in most cases, OCD follows action becomes unnecessary (Albert Ellis Institute, a cyclical pattern in which compulsive actions 2005). The most commonly used behavioural initially lead to lessening of aversive obsessional strategy involves Exposure and Response Preven- thoughts, indicating that compulsive actions may tion (ERP; Foa & Kozak, 1986; Lindsay, Crino, be negatively reinforced by escape from obsessive & Andrews, 1997). ERP is based largely on thoughts. However, usually obsessive thoughts principles of classical conditioning, using flooding soon re-appear, indicating that compulsive ac- and/or counter-conditioning (Watson, 1924) and tions in turn may function to positively reinforce systematic de-sensitisation (Wolpe, 1958). ERP obsessive thought patterns. While the specific for ODC patients usually includes exposure to a thoughts and actions differ from one individual to hierarchy of obsessions and the requirement to another, this cyclical positive-negative reinforce- prevent responding to these thoughts with com- OCD and habit reversal 3 pulsive action. This is achieved through in vivo 2005), HRT is not routinely used with OCD practice during the therapy session and homework patients and there are no detailed descriptions or tasks. In cases where in vivo therapy is impossible published evidence of effectiveness. In this paper, or impractical, imaginal exposure is used for the potential of HRT with a treatment refractory which short stories based on obsessions can be ODC patient is explored. audio taped and then replayed for exposure. While about 25% of patients
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